Clinical and Investigative Study of Hirsutism

Abstract

Introduction: Hirsutism is the presence of excessive terminal hair in androgen-dependent areas in a female with varied aetiology. The most common endocrine disorder leading to hirsutism is Polycystic Ovary Syndrome (PCOS). Hirsutism can be androgen induced or non-androgen induced. Hyperandrogenism with hirsutism can be associated with various signs and symptoms such as Acanthosis Nigricans (AN), obesity, acne, virilisation, Female Pattern Hair Loss (FPHL) and pelvic mass. Aim: To assess the aetiology of hirsutism and to study the clinical, biochemical characteristics of these patients along with other associations like AN, hypothyroidism, PCOS, FPHL, acne, deepening of voice and clitoromegaly. Materials and Methods: A retrospective cross-sectional study in which medical records of patients having hirsutism from prefilled proformas attending the outpatient department during June 2016 to May 2018 were analysed. Fifty patients with modified Ferriman-Gallwey (mF-G) score of eight or more were reviewed with respect to age, sex, history of symptoms including the menstrual history, height, weight, Waist Circumference (WC) and Body Mass Index (BMI). Hormonal profile {Serum Free and total testosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), prolactin, free tri-iodothyronine, free tetra-iodothyronine, Thyroid Stimulating Hormone (TSH), fasting blood sugar, fasting insulin and fasting lipid profile} and transabdominal ultrasonography reports were assessed. Statistical analysis was done using STATA version 14.0 software. Chi-square test was used for comparison between categorical variables (viz., acne and menstrual history). One-way ANOVA (Analysis of variance) was used for comparison of means of WC, BMI, mF-G score and hormone profile in different aetiologies of hirsutism for normalised data and Kruskal-Wallis ANOVA test was used for non-normalised data. Multiple comparisons were performed by Bonferroni t-test to compare any type of significant difference of study parameters between two aetiologies. The p-value of <0.05 was considered significant. The p-value of <0.001 was considered as highly significant. Results: The mean age of the patients was 29.42±10.83 years. The causes of hirsutism were Idiopathic Hirsutism (IH) (40%), PCOS (32%), Hyperandrogenic Insulin Resistant Acanthosis Nigricans Syndrome (HAIR-AN) (16%), Hypothyroidism (8%) and late Onset Congenital Adrenal Hyperplasia (CAH) (4%). Associated signs of hyperandrogenism included acne (40%), FPHL (26%), AN (20%), deepening of voice (4%) and clitoromegaly (4%). Serum LH and LH:FSH ratio was significantly raised in PCOS and CAH. Serum 17-OH progesterone was significantly raised in CAH. WC and serum fasting insulin were statistically significant in HAIR-AN group as compared to other groups. Homeostatic Model Assessment for Insulin Resistance (HOMAIR) was significantly raised in HAIR-AN group as compared to CAH but there was no statistically significant difference between other groups (PCOS, IH and hypothyroidism). Conclusion: Hirsutism though a benign condition should be thoroughly evaluated. Idiopathic hirsutism was most common cause in this study. WC, serum fasting insulin and HOMA-IR were statistically significant in HAIR-AN patients which signify the importance of ruling out insulin resistance in patients presenting with hirsutism and AN as they require additional management.

Keywords

• acanthosis nigricans
• hyperandrogenism
• hypothyroidism
• insulin resistance
• polycystic ovarian syndrome